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Thank you Mr. Chairman and members of the Committee.

My name is Terence M. Keane, Ph.D. and I am a clinical psychologist from Boston and today I am representing the Association for VA Psychologist Leaders serving as this year’s President. Our organization is more than twenty-seven years old and its mission is to improve and enhance mental health services for military veterans through the delivery of outstanding clinical services, the conduct of relevant behavioral health research, and the training of the next generation of psychologists.

In my career I’ve served as the Chief of Psychology at three different VA’s, first at the Sonny Montgomery VA Medical Center in Jackson, Mississippi; next at the Boston VA Medical Center, and most recently at the consolidated VA Boston Healthcare System. Currently, I am the Associate Chief of Staff for Research and Development at the VA Boston and Professor of Psychiatry, Psychology, and Behavioral Neuroscience at Boston University. However, to be clear, my comments today are as the President of the Psychology Leadership group.

Our organization is concerned, as is the Nation, about American troops’ exposure to high levels of combat stress and its impact on individuals, their families, and their communities. Thus, our comments are relevant to the active military workforce, veterans, as well as those serving in the Reserves and the National Guard. Each group presents a special challenge for delivering optimal mental health services. Stigma, fear of alienation, and access influence who does and who doesn’t seek mental health services in these groups. All groups will one day consider getting healthcare in VA.

As mental health professionals we are committed to providing the best possible services to returning troops. As well, we are committed to employing the most contemporary means of providing these services with the goals of fostering positive adjustment and minimizing long term, chronic mental health problems. The President’s New Freedom Commission and the VA’s Action Agenda contain important new ways to manage the large number of veterans with mental health and behavioral health problems. These initiatives creatively driven by VA mental health experts need to be fully resourced, implemented, evaluated, and monitored.

Today, VA may well be the finest mental health system in the United States, providing an array of services for treating trauma, substance abuse, and other serious combat related mental health problems. Mental health professionals provide services to veterans and their families in Vet Centers, Primary Care Clinics, Specialized PTSD Clinics, Substance Abuse Programs, Homeless Programs, and in general mental health clinics.

As VA has changed in the past ten years so have the models of mental health care delivery. To keep pace, the mental health workforce in VA is in need of a major educational initiative so that our skills in prevention and treatment can be provided to the growing numbers of new veterans coming to VA for mental health care. Models of individual psychotherapy need to be used judiciously while supplemented by the use of the modern methods of tele-mental health, integrated primary care and mental health care, the use of self help methods, the internet and web based interventions, and peer assisted support.

For the returning troops all efforts should be towards the promotion of recovery and the fostering of independence. But implementation of these new interventions requires a retooling of the workforce with significant attention to the evidence bases derived from VA specialized programs, private sector services, and from other healthcare systems worldwide. Our organization is committed to working with VA in such an educational initiative. Such a broad based educational effort will require modest resources to establish and maintain.

In addition, our organization supports greater integration and collaboration with the Department of Defense’s healthcare system. Combined initiatives in health care, such as the use of a common, integrated medical record, are critical to achieving our mission of providing the best possible healthcare to military veterans.

Initiatives that promote collaborative care, collaborative education, and collaborative research between VA and DOD are critical to the success of our mission. We support those initiatives that bring the healthcare and the mental healthcare services of these two agencies into greater alignment. While many examples of this collaboration exist, more are needed in order to optimally provide mental health services for military veterans and their families. VA and DOD healthcare services can benefit from additional collaborations centered around the people to be served, whether these services are to be provided now or five years from now.

We are aware of the limitations that exist for provision of mental health services within VA to the Guard, Reservists, and veteran’s families. We support the changes in eligibility that have been already made and support increased inclusion of mental health services for families that are affected by activation, deployment, injury, or death.

Although most cases of PTSD develop shortly after combat service, it is indeed the case that, for some, mental health needs can emerge years after their military service. Two months ago I spoke on the phone with a veteran who happened to be a psychologist in his eighties who was part of the American forces that took beachheads in Italy during World War II. He described his experiences and wondered out loud to me if he needed my help; his wife urged him to call VA as she thought he was becoming increasingly preoccupied with his distressing war experiences. Reports of a gap of decades between war and the appearance of war related distress are all too common.

The jewels in VA mental health services exist in the specialized programs that it possesses. Specialized services generated the outstanding reputation VA has for its work in war related PTSD, Substance Abuse, Geriatric Mental Health, and in the care of those with psychotic conditions. Preserving these specialized services is central to the excellence of VA noted in the New England Journal of Medicine and the Lancet in 2004. Buttressing these specialized programs are VA’s mental health centers of excellence. The Mental Illness Research Education and Clinical Centers (i.e., MIRECC’s), the National Center for PTSD, the Substance Abuse Centers of Excellence, and the Geriatric Research Education and Clinical Centers (GRECC’s) all enhance the luster of the VA system of mental health care. We urge continued strong support for these leading lights in VA.

In the mid 1980’s VA conducted the National Vietnam Veterans Readjustment Study. This study was remarkable in two respects. First, it was the first time that any country had ever attempted to systematically study the psychological and social impact of participation in a war; second, it was the first mental health study employing a nationally representative sample of Vietnam veterans. Today we have the opportunity to understand the long term psychological and physical impact of participation in war as Vietnam veterans are reaching their late fifties. Our organization supports the completion of the follow-up study of Vietnam veterans as it will provide us an outstanding opportunity to plan for the future needs of this, the largest group of veterans at this time. As well, this study will further help us in preparing for the needs of the newest group of veterans from OEF-OIF.

Leadership in research on veterans’ mental health problems is one of the major contributions of all VA. To maintain this resource there is a distinct need to train younger investigators as the research work force is graying; additional fellowships are needed in order to insure that there is a new generation of researchers in mental health trained to study veterans’ health problems. Once their training is complete, there is a need for research funding that will support them early in their careers. Our group supports the gradual increase in the proportion of the research budget allocated to mental health and behavioral health problems. If the initiative to gradually increase the mental health research budget to approximately 20% of the total Research budget is successful, it will insure that the country has a younger generation of researchers dedicated to studying veterans’ mental health problems.

In April, Psychology leadership convened its annual meeting in Dallas, Texas. Our Keynote Speakers were the Honorable Gordon H. Mansfield, Deputy Secretary of VA and the Honorable Jonathan Perlin, Undersecretary of Health. Each exhorted members of our group to assume even greater leadership roles in promoting the recovery and rehabilitation of returning injured veterans. Mr. Mansfield requested from our group a list of recommendations for him to consider in improving services for the newest veteran cohort using our healthcare system. A group of dedicated members from AVAPL, the APA, and APA’s VA Section of Public Service Psychologists spent countless hours identifying and articulating these recommendations. They were recently forwarded to Mr. Mansfield for his review. I am including herein a number of the most immediately relevant recommendations from this effort:
I. Contributions to Returning OEF/OIF Veterans and Their Families
VA mental health professionals are prepared to foster a seamless transition between DOD and DVA by providing treatment for those OEF and OIF troops previously identified by DOD providers. There is a need for specialists in the care of male and female combatants and the disorders that they preferentially display.

We also recognize that the psychological wounds of OEF/OIF veterans will also affect their loved ones. Family members are critical partners in promoting the healing and recovery process of the veteran.

OEF/OIF veterans are more likely to seek medical services than services identified as "mental health" as they attempt to return to normal lives. Mental health professionals on site in primary care clinics, working either as direct care providers or as immediate consultants to the primary care provider, can facilitate the identification of the symptoms of traumatic stress and other psychological disorders, or can provide timely, patient-centered behavioral interventions when appropriate.
Recommendation 1: We support the establishment of at least one Post Traumatic Stress Disorder Clinical Teams (PCTs) in every medical center and endorse a staffing profile that includes the expertise to provide a range of psychological services, including special services for women veterans as well as services to spouses and families.
II. The Treatment of Veterans with Physical Injuries

Members of the Military are sustaining multiple severe injuries as a result of suicide bombers, rockets, and improvised explosive devices. Accordingly, many veterans will be treated for polytraumatic injuries that result in physical, cognitive, psychological, and/or functional impairments. These conditions frequently occur in combination with other disabling conditions such as amputation, auditory and visual impairments, spinal cord injury (SCI), post-traumatic stress disorder (PTSD), and other mental health conditions.

Through specialized training, Behavioral Health professionals bring expertise in rehabilitation, the neurosciences, and the addictions and can make unique contributions to the care of veterans with these conditions.
Recommendation 2: We recommend that mental health professionals be present as full time members of treatment teams in rehabilitation medicine programs across the country in order to provide the highest standard of care possible. Providing behavioral health services through a model of integrated care with other health care specialists offers the best opportunity for early detection of mental health problems, for promoting optimal recovery, and facilitating adherence to medical and rehabilitative regimens.
Recommendation 3: To identify and to disseminate the most effective treatment strategies for promoting full recovery from polytrauma injuries, Interprofessional Research Fellowships should be established through Office of Academic Affiliations in which psychologists, physicians, and other rehabilitative health care specialists will work collaboratively and from transdisciplinary perspectives to identify best practices of care.
III. Advancing the Recovery and Rehabilitation Model of Treatment
The VA’s Action Agenda for the President’s New Freedom Commission on Mental Health promotes a treatment model based on recovery and rehabilitation for veterans diagnosed with serious mental illnesses. Psychologists and Psychiatrists are, and historically have been, the team leaders in VA Mental Health recovery and rehabilitation programs. We endorse this core value model of recovery and are committed to achieving the goal of this model: "Recovery is....to live a fulfilling and productive life despite a disability" (President’s New Freedom Commission Report).
Recommendation 4: We recommend that responsibility for a Recovery Model and Rehabilitation Model, and its implementation across the country, be given high priority within VHA and by the MHSHG. Planned resources should be allocated to this objective and a monitoring program established to insure that these resources are utilized to meet these goals.
IV. Adopt Best Practice Guidelines for PTSD Compensation and Pension Examinations
Psychologists and Psychiatrists collaboratively developed the Best Practice Manual for Post-traumatic Stress Disorder (PTSD) Compensation and Pension Examinations. These guidelines were designed to provide clinicians with the optimal means for arriving at the most accurate information for the Adjudicator examiners. They were developed in a collaborative effort between Veterans Benefits Administration (VBA) and the National Center for PTSD (VHA). As the number of veterans seeking compensation for war-related injuries, including PTSD, continues to grow, it is essential that this entry point into the VA’s health care system provide accurate information upon which future treatment needs and compensation can be based.
Recommendation 5: We recommend that the Best Practice Guidelines for PTSD Examinations be presented to the National Leadership Board (NLB) as potentially one of the system’s most cost beneficial initiatives. The methods outlined therein should reduce the backlog and improve the confidence of the Adjudicators in their decisions based on available data. The NLB should take necessary steps to assure that these Guidelines are adopted on a nationwide basis.
V. Promote the Further Expansion of Telehealth into Behavioral and Mental Health Field
We recognize that a significant number of veterans seeking behavioral and mental health services live in rural areas and lack either the time and/or resources to travel to VA stations. We also recognize the growing demand for mental health services. Research has documented the benefits to veterans of receiving treatment via a telehealth system. Web-based interventions now exist for PTSD, depression, psychoses, and other behavioral and mental health needs. Psychologists support the use of telehealth in providing a variety of clinical health services and recognize this is a practice that is a part of the Under Secretary’s Mission and Planning Strategies vision for promoting clinical effectiveness. Telehealth will foster a culture that encourages innovation while providing enhanced access to mental health care.
Recommendation 6: We recommend that additional resources be directed toward the expansion and implementation of telehealth services for treating behavioral health problems. To achieve this goal, resources are needed for an infrastructure to support practice, as well as education and training for behavioral health providers, and for research to evaluate the impact of these services.
VII. Revising the Current Disability Compensation System.

Historically, one of the major concerns of VA mental health professionals has been that the current disability and compensation system potentially rewards “staying ill”. Fear of losing disability payments can be a disincentive for veterans to engage in recovery based activities. We would welcome the opportunity to participate in a review of current compensation practices with an eye towards the development of policies that would support veterans as they transition back to health, but would permit those in recovery to have a safety net when and if they experience a deterioration of their condition

Recommendation 7: We recommend that representatives of Mental Health be appointed to the new Veteran’s Disability Benefits Commission or an internal implementation group to help address the strengths and limitations of the current disability compensation system.


Thank you for this opportunity to speak on behalf of my organization and we urge the committee to work in collaborative ways with VA, AVAPL, and other professional groups to address the needs of current and future military veterans and their families.